Table of contents

Definitions

Attendant care services:

Attendant care services provide assistance in the home for personal care and activities of daily living. (See definition of personal care, below.)

Bundled:

A bundled procedure code isn’t payable separately because its value is accounted for and included in the payment for other services. Bundled codes are identified in the fee schedules.

Pharmacy and DME providers may bill for services that are bundled in the fee schedules for other provider types. This is because, for these provider types, there isn’t an office visit or a procedure into which supplies can be bundled. Coverage of these services will depend on the department's policies.

By report (BR):

A code listed in the fee schedule as “BR” doesn’t have an established fee because the service is too unusual, variable, or new. When billing for the code, the provider must provide a report that defines or describes the services or procedures. The insurer will determine an appropriate fee based on the report.

Payment policy: Attendant care services

Prior authorization

All attendant care

All attendant care services require prior authorization.

The insurer will determine the maximum hours and type of authorized attendant care based on the nursing assessment of the worker’s personal care needs that are proper and necessary and related to the worker’s industrial injury.

Note: For a definition of personal care, see “Definitions” at the beginning of this chapter.

Attendant care services may be terminated or not authorized if:

Behavior of worker or others at the place of residence is threatening or abusive, or

Worker is engaged in criminal or illegal activities, or

Worker doesn’t have the cognitive ability to supervise attendant and there isn’t an adult family member or guardian available to supervise the attendant, or

Residence is unsafe or unsanitary and places the attendant or worker at risk, or

Worker is left unattended during approved service hours by the approved provider.

The insurer will notify the provider in writing if current approved hours are modified or changed.

Wound care

When attendant care agencies are providing care to a worker with an infectious wound, prior authorization and prescription from the treating physician is required.

Worker travel

Workers who qualify for attendant care and are planning a long distance trip must inform the insurer of the plans and request specific authorization for coverage during the trip.

Temporary or respite care

Temporary or respite care requires prior authorization. The agency providing respite care must meet L&I criteria as a provider of home health services.

The insurer can approve short term agency attendant care services for a spouse or family member who provides either paid or unpaid attendant care when respite (relief) is required.

Note: Spouses won’t be paid for respite care.

If a current nursing assessment isn’t available, a nursing evaluation will be conducted to determine the level of care and the maximum hours of service required. (Also see “Independent nurse evaluation reports” under “Services that can be billed,” below.)

If in-home attendant care can’t be arranged with an agency, the insurer can approve a temporary stay in a residential care facility.

The insurer will notify the agency in writing when services are approved.

The insurer will notify the provider in writing if current approved hours are modified or changed.

Who must perform these services to qualify for payment

Attendant care agency requirements

Attendant care services must be provided by an agency that is licensed, certified, or registered to provide home health or home care services. Attendant care agencies must have registered nurse (RN) supervision of caregivers providing care to a worker.

The agency providing services must be able to provide the type of attendant care and supervision necessary to address the worker’s medical and safety needs. Agency services can be terminated if the agency can’t provide the necessary care.

Attendant requirements

Workers must not be left unattended during approved service hours.

Attendants for workers may be:

Registered aides, or

Certified nurse’s aides, or

Licensed practical nurses, or

RNs.

Respite care

The agency providing respite care must meet L&I criteria as a provider of home health services.

Spouse attendant care

Spouses may continue to bill for spouse attendant care if they:

Aren’t employed by an agency, and

Provided insurer approved attendant services to the worker prior to October 1, 2001, and

Met criteria in the year 2002.

Note: Also see “Payment limits” for spouse attendant care, below.

Link: For more information on laws about spouse attendant care, see WAC 296-23-246 .

Services that can be billed

Attendant services

HCPCS code

Description

Max fee

S9122

Attendant in the home provided by a home health aide certified or certified nurse assistant per hour

$26.43

S9123

Attendant in the home provided by a registered nurse per hour

$57.48

S9124

Attendant in the home provided by licensed practical nurse per hour

$41.95

Agency care services

The agency can bill workers for hours that aren’t approved by the insurer if the worker is notified in advance that they are responsible for payment.

Independent nurse evaluation reports

An independent nurse evaluation requested by the insurer, may be billed under “Nurse Case Manager” or “Home Health Agency RN” codes, using their respective codes. (See more information about these reports under “Requirements for billing,” below.)

Mileage, parking, and other travel expenses of the attendant when transporting a worker are the responsibility of the worker.

(Also see “Requirements for billing,” below.)

Requirements for billing

Agency care services

In addition to prior authorization, attendant care agencies must obtain a provider account number and bill with the appropriate code(s) to be reimbursed for services.

Independent nurse evaluation reports

All RN evaluation reports must be submitted to the insurer:

Within 15 days of the initial evaluation, and then

Annually, or

When the worker’s condition changes and necessitates a new evaluation.

Daily chart notes

Documentation to support daily billing must be submitted to the insurer and include:

Begin and end time of each caregiver’s shift, and

Name, initials, and title of each caregiver, and

Specific care provided and who provided the care.

Wound care

In addition to prior authorization, when caregivers are providing wound care a prescription from the treating provider is required to bill for infection control supplies (HCPCS code S8301).

An invoice for the supplies must be submitted with the bill.

Travel that isn’t related to medical care

A worker who qualifies for attendant care and is planning a long distance trip, must inform the insurer of the plans and request specific authorization for coverage during the trip.

The worker must coordinate the trip with the appropriate attendant care agencies. (Also see “Services that aren’t covered,” above.)

Payment limits

Attendant services

RN supervision services aren’t paid separately and are included in the hourly fee as business overhead.

Attendant care providers can’t bill for services the attendant performs in the home while the worker is away from the home.

Agency care services

The agency can’t bill for more than 12 hours per day for any one caregiver.

The agency can’t bill for care during the time the caregiver is sleeping.

Spouse attendant care

Spouse attendants may bill up to 70 hours per week. Also:

Exemptions to this limit will be made based on insurer review. The insurer will determine the maximum hours of approved attendant care based on an independent nurse evaluation, which must be performed yearly, and

If the worker requires more than 70 hours per week of attendant care the insurer can approve a qualified agency to provide the additional hours of care, and

The insurer will determine the maximum amount of additional care based on an RN evaluation.

Payment policy: Home health services

Prior authorization

Home health services

All home health services require prior authorization and must be requested by a physician. The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.

When services become proper and necessary to treat a worker’s accepted condition, the insurer will pay for aide, RN, physical therapy (PT), occupational therapy (OT), and speech therapy services provided by a licensed home health agency.

Home health services may be terminated or denied when the worker’s medical condition and situation allows for outpatient treatment.

Durable medical equipment (DME)

Durable medical equipment may require specific authorization prior to purchase. Covered HCPCS codes listed as bundled in the fee schedule are separately payable to home health and home care providers for supplies used during the home health visit.

Link: To see which codes require prior authorization, see the HCPCS fee schedule at http://feeschedules.Lni.wa.gov . Codes that require prior authorization are noted with a “Y” in the “Prior auth” column.

Note: See definition of bundled in “Definitions” at the beginning of this chapter.

Worker responsibilities

The worker is expected to be present and ready for the home health nurse or therapist treatment.

Payment policy: Home infusion services

(See definition of home infusion services in “Definitions” at the beginning of this chapter.)

Links: For additional information on home infusion services, see WAC 296-20-1102 .

Prior authorization

Regardless of who is providing services, prior authorization is required for:

Home infusion nurse services,

Drugs, and

Any supplies.

The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.

Home infusion services can be authorized independently or in conjunction with home health services.

Home infusion skilled nurse services will only be authorized when infusion therapy is approved as treatment for the worker’s allowed industrial condition.

Who must perform these services to qualify for payment

Home infusion nurse services

Skilled nurses contracted by the home infusion service provide infusion therapy, as well as:

Education of the worker and family,

Evaluation and management of the infusion therapy, and

Care for the infusion site.

Drugs

Drugs for outpatient use, including infusion therapy drugs, must be billed by pharmacy providers, either electronically through the point-of-service system or on appropriate pharmacy forms (Statement for Pharmacy Services, Statement for Compound Prescription or Statement for Miscellaneous Services) with national drug codes (NDCs or UPCs if no NDC is available).

Note: Total parenteral and enteral nutrition products may be billed by home health providers using the appropriate HCPCS codes.

If rental or purchase of an infusion pump is medically necessary to treat a patient in the home, refer to the payment policy for “Home infusion services” in the Home Health Services chapter for more information.

Services that can be billed

Home infusion nurse services and drugs

These home infusion CPT® codes may be billed for initial establishment of nutritional therapy for the worker when services have been authorized:

CPT® code

Description and notes

Max fee

99601

Skilled RN visit for infusion therapy in the home. First 2 hours per visit

$151.71

99602

Skilled RN visit for each additional hour per visit

$63.80

Wound care and medical treatment supplies

Home health and home infusion services may bill appropriate HCPCS codes for wound care and medical treatment supplies.

Covered HCPCS codes listed as bundled in the fee schedule are separately payable to home health and home care providers for supplies used during the home health visit.

Note: See definition of bundled in “Definitions” at the beginning of this chapter.

Requirements for billing

Home infusion nurse services

For administering home injections or nutritional parenteral solutions only, use the RN visit code G0154 (Services of skilled nurse in home health setting, each 15 minutes).

Drugs

Drugs for outpatient use, including infusion therapy drugs, must be billed by pharmacy providers, either electronically through the point-of-service (POS) system or on appropriate pharmacy forms (Statement for Pharmacy Services, Statement for Compound Prescription or Statement for Miscellaneous Services) with national drug codes (NDCs or UPCs if no NDC is available).

Note: Total parenteral and enteral nutrition products may be billed by home health providers using the appropriate HCPCS codes.

Supplies

The rental or purchase of infusion pumps must be billed with the appropriate HCPCS codes.

Payment policy: In-home hospice services

Prior authorization

In-home hospice services must be preauthorized and may include chore services. The insurer will only pay for proper and necessary services required to address physical restrictions caused by the industrial injury or disease.

Services that can be billed

HCPCS code

Description and notes

Max fee

Q5001

Hospice care, in the home, per diem. Applies to in-home hospice care.

By report

Note: See definition of by report in “Definitions” at the beginning of this chapter.